PAYMENT POLICY

PLEASE REVIEW CAREFULLY AND ASK STAFF TO EXPLAIN TERMS THAT ARE UNFAMILIAR OR CONFUSING. SIGNATURE IS REQUIRED.

Thank you for choosing us for your healthcare needs. Our relationahsip is best served when expectations are clearly understood. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we developed this payment policy to help you better understand your financial responsibilities in relation to the medical care we provide. We ask that you read the policy, ask any questions you may have and sign your name in the Acknowledgement section. A copy will be provided to you upon request.

All patients must provide us with valid identification (driver’s license) and a current and valid copy of your primary (and secondary if applicable) insurance card(s) to provide proof of insurance. We do our best to confirm your insurance eligibility and determine what amounts you will owe prior to your visit, but sometimes that amount changes depending on the scope of services actually provided.

Our policy is to collect amounts due from patients, including co-payments, deductibles and co-insurance amounts on the same day that services are rendered unless other arrangements have been made in advance. The practice accepts cash, personal checks, debit and credit card payments although additional fees will apply if a persoanl check is denied for insufficient funds. The practice reserves the right to deny non-urgent care to patients that refuse to manage his or her responsibility.

Insurance
Our practice is contracted with most insurance companies including Medicaid and Medicare and we will submit claims to those companies on your behalf. Insurance plans may restruct the type and/or number of services covered and/or the number or type of eligible providers. Knowing your insurance benefits is your responsibility. Please contact your insurance company with questions you may have regarding your coverage and confirm that our doctors participate with your insurance plan, whether or not a primary care referral or insurance authorization is required, and that the services you require are actually covered by your health plan. If you are insured by a plan we do business with but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage.

If we are not contracted with your insurance company, payment for all services is expected at the time of service. As a courtesy, we will submit claims to your insurance company. If you do not have insurance coverage, payment for all services is expected at the time of service.

Co-payments and deductibles
All co-payments deductibles and co-insurance amounts required by your insurance company must be paid at the time of service without exception.

Non-covered services.
Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by your insurance plan. You must pay for these services in full at the time of visit.

Claims submission.
We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

Coverage changes.
If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

Nonpayment.
Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and may be discharged from this practice.

Missed appointments.
You will be charged a fee of $50 for missed appointments not canceled at least one day in advance, and late cancelations (less than 24 hours). These charges will be your responsibility and billed directly to you. Please verify what this office charges for missed appointments fee with the Front Desk or office manager. Please help us to serve you better by keeping your regularly scheduled appointment. Excessive missed appointments will result in discharge from the practice.

Minor Patients
The adult accompanying a minor and/or the parent(s) (or guardian(s) of the minor) is responsible for payment at the time of service. Non-emergency treatment for unaccompanied minors will be denied unless payment arrangements have been made in advance.

Medical Records
We do not charge for sending medical records to another health care provider. If you request a hard copy of your medical record there will be $1.00 per page charge for the first 25 pages, and $.25 for each additional page.

Billing Questions
If you have a billing related question please contact Florida Pediatric Associates LLC, 727-456-3288.

The undersigned certifies that he/she read and understand this document and has the legal right and is duly authorized to execute this document and accepts its terms as the patient or the parent or legal guardian of the patient.

AUTHORIZATION AND CONSENT FOR TREATMENT

 

PLEASE REVIEW CAREFULLY AND ASK STAFF TO EXPLAIN TERMS THAT ARE UNFAMILIAR OR CONFUSING.

THEN, INITIAL APPLICABLE CONSENTS AND SIGN AT BOTTOM OF FORM

NOTICE OF PATIENT FINANCIAL RESPONSIBILITY & RELEASE OF INFORMATION

PLEASE REVIEW CAREFULLY AND ASK STAFF TO EXPLAIN TERMS THAT ARE UNFAMILIAR OR CONFUSING. SIGNATURE IS REQUIRED. 

Statement of Financial Responsibility
I understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all expenses incurred. In consideration of services rendered to the patient named herein, I agree to be financially responsible and to pay charges for all services ordered by the provider(s). I understand that any balance due as a result of being uninsured or under-insured is payable immediately. I further understand that if I fail to maintain consistent payments, my account may be referred to a collection agent and/or attorney, and I agree to pay all collection related charges. I understand that if my insurance has a pre-certification or authorization requirement, it is my responsibility to notify the carrier of services rendered according to the plans provisions. I understand that failure to do so will result in reduction or denial of benefit payment and I will be responsible for all balances.

Assignment of Benefits
I request that payment of authorized insurance benefits, including Medicare, if I am a Medicare beneficiary, be made on my behalf to Florida Pediatric Associates for any medical services provided to me by that organization.

Release of Medical Information
I understand that Florida Pediatric Associates, its business associates, any treating physician/surgeon and/or my insurance company may obtain, use and/or disclose information for the purposes of treatment, payment and normal health care operations. This use and disclosure may include collection agencies and credit bureaus. Information may include psychiatric, drug abuse, alcohol and/or HIV status. I understand that if I do not consent to release of information for payment purposes, the Florida Pediatric Associates and other health care providers will be unable to bill my insurance company or other party which is or may be responsible for payment for the services documented by the withheld information, and I will be billed directly for these services. Patients with implantable devices consent to the release of their Social Security numbers to the device manufacturer to comply with the Safe Medical Devices Act. For a more detailed description of uses and disclosures for treatment, payment or normal health care operations, review Florida Pediatric Associates Notice of Privacy Practices. I authorize the release of any medical or other information necessary to determine these benefits or the benefits payable for related equipment or services to the organization, the Health Care Financing Administration, my insurance carrier or other medical entity. A copy of this authorization will be sent to the Health Care Financing Administration, my insurance company or other entity if requested. The original will be kept on file by the organization. I acknowledge that I have received information regarding my rights to privacy of information under HIPAA regulations, as described in the Florida Pediatric Associates Notice of Privacy Practices.

Notice of Unauthorized, Non-Covered, or Out of Plan Services
I am aware that some services performed by Florida Pediatric Associates may be considered “non-covered” by my insurance carrier or Medicare. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I understand that if my insurance plan does not consider any service rendered a covered service or if my insurance plan has not authorized this service, they will not pay for the service rendered during this outpatient visit. I also understand and acknowledge that in the case of Out of Plan/Network services, there may be reduced benefits and I may be required to pay a larger co-payment, coinsurance or other charge. I am responsible for the entire bill or balance of the bill as determined by the practice and/or my health care insurer if the submitted claims or any part of them are denied for payment.

Waiver of “Usual, Customary and Reasonable” Clauses - (For patients with “Out-of-Network” coverage).
I acknowledge that the fee charged by the Practice for services rendered to me, or to the person for whom I assume financial responsibility, may exceed the fees considered “usual, customary and reasonable,” due to specialized services and staff. However, I agree to pay the Practice fees in full, even if the amount is greater than what I am reimbursed from my insurance company.

For Medicare Recipients Only
I certify the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I request that payment of authorized Medicare benefits be made on my behalf to the Practice for any services furnished to me by Practice physician or other provider. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for the related services. In the case of Medicare Part B benefits, I request payment either to myself or to the party who accepts assignment.

The undersigned certifies that he/she read and understand this document and has the legal right and is duly authorized to execute this document and accepts its terms as the patient or the parent or legal guardian of the patient.

CONSENT FORM FOR THE E-PRESCRIBE PROGRAM

Divisions of Florida Pediatric Associates, LLC have implemented e-prescribing as part of an on-going effort to improve your health care. E-prescribing refers to a system used to submit prescriptions electronically to a pharmacy of your choice. By eliminating paper, e-prescribing creates a more efficient and safer process for patients to access their medications. This electronic process aims to prevent prescription errors and improve patient safety. The ePrescribe Program may also include:

Formulary and benefit transactions – Provides information to your health care practitioner about which drugs are covered by your drug benefit plan.

Fill status notification - Allows your health care practitioner to receive an electronic notice from the pharmacy telling them if your prescription has been picked up, not picked up, or partially filled.

Medication history transactions - Provides your health care practitioner with information about your current and past prescriptions to minimize potential medication issues and adverse medication events. Medication history data can indicate: compliance with prescribed regimens; therapeutic interventions; drug-drug and drug-allergy interactions; adverse drug reactions; and duplicative therapy.

The medication history information would include medications prescribed by your Florida Pediatric Associates health care practitioner as well as other health care providers involved in your care. Medication history information may include sensitive information including, but not limited to, medications related to mental health conditions, venereal diseases/sexually transmitted diseases, genetic diseases, and HIV/AIDS. As part of this Consent Form, you specifically consent to the release of this and other sensitive health information.

CONSENT

By signing this consent form you agree that your Florida Pediatric Associates health care practitioner may request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payors for treatment purposes.

You may decide not to sign this form. Your choice will not affect your ability to get medical care, payment for your medical care, or your medical care benefits. Your choice to give or to deny consent may not be the basis for denial of health services. You also have a right to receive a copy of this form after you have signed it.

This consent form will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing but if you do, it will not have an effect on any actions taken prior to receiving the revocation.

Understanding all of the above, I hereby provide informed consent to Florida Pediatric Associates, LLC health care practitioner to enroll me in this ePrescribe Program. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

I hereby authorize Florida Pediatric Associates to release medical, psychological, psychiatric, developmental-alcohol and/or drug abuse, human immunodeficiency virus (HIV) testing and treatment, AIDS related information, and genetic information as it concerns the above referenced patient as follows:

If requesting an unencrypted format, by signing below I acknowledge that I understand the inherent risks involved with sending and receiving information in an unencrypted, unsecured, format (such as regular email or unencrypted disc). Such risks include misdirected messages, email intrusion, interception, or views by unauthorized parties.

This authorization is voluntary. Refusal to sign this authorization will not lead to an impact on my treatment, or refusal by my Florida Pediatric Associates provider to provide treatment services to me/my child. I understand that my provider may charge a reasonable fee, as allowed by law, for a copy of my/my child’s health information. I may revoke this authorization by submitting my request in writing to the clinic or department where I submitted this authorization but understand that such revocation will not apply to actions already taken by my health care provider prior to my revocation.

 

I also understand that once my/my child’s medical information is disclosed based on this authorization, it may be further used or disclosed and will no longer be protected by state or federal privacy laws.

I understand that I may:

1. Request a copy of this authorization.
2. Revoke this authorization (except to the extent that action was already taken in accordance of this signed authorization) at any time by notifying this office in writing (the appropriate form can be obtained from office staff).
3. Refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment or my eligibility for benefits; however the office has the right to deny the above request.
4. Inspect or obtain a copy of any information used or disclosed under this agreement and I am aware that I must request to do so with the completion of the appropriate form.

I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be re-disclosed and would no longer be protected by these regulations. Additionally, the authorized provider would not be held responsible for any re-disclosures by the person or organization that receives the information. My provider may also share my protected health information with family members and friends that I choose to involve in my care or payment for my care even if not listed above, to the extent allowed by applicable privacy laws.

REQUEST AND AUTHORIZATION TO EMAIL

PROTECTED HEALTH INFORMATION

By signing below, you acknowledge that you understand the inherent risks involved with sending and receiving information in an unencrypted, unsecured, format (such as regular email or unencrypted disc), and you agree to accept these risks. Such risks include misdirected messages, email intrusion, interception, or views by unauthorized parties. Additionally,

1. This Request applies only to Sleep Medicine and Pediatric Pulmonary Specialists. If you would like to request to communicate via e-mail with another healthcare provider or office, you must complete a separate request for that office.

2. Florida Pediatric Associates does not recommend communicating health information that is sensitive in nature and that is provided additional protections under state and federal law (e.g., HIV/AIDS information, substance abuse treatment records information, mental health information, social security numbers, credit card information) via email.

3. This form only pertains to general communications. To request copies of your medical records, please contact the Florida Pediatric Associates office where you are being treated to submit your request in writing via the Request for Access to Protected Health Information Form.

4. Your request is not effective until you receive and respond appropriately to a test e-mail from us to verify your email account. Please select the test question you want to use below and provide us with your answer.

NOTICE OF PRIVACY PRACTICES

EFFECTIVE DATE JANUARY 1, 2024 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS DOCUMENT CAREFULLY

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice.  We are required to abide by the terms of this Notice of Privacy Practices.  This Notice will remain in effect until it is amended or replaced by us.

We reserve the right to revise or amend this Notice of Privacy Practices provided law permits the changes.  Any revision or amendment to this notice will be effective for all health information maintained, created and/or received by us before the date changes were made and for any health information we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location, and you may request a copy of our most current Notice at any time.  You may request a copy of our Privacy Notice at any time by contacting the manager of this office or by contacting our Compliance Office.

For questions regarding this notice, please contact the Florida Pediatric Associates Compliance Office at:

1800 Dr. Martin Luther King Jr. Street North

St. Petersburg, FL 33704

Phone:   (866) 635-8765

E-mail: icomply@floridapediatrics.com

WHO WILL FOLLOW THIS NOTICE

This notice describes the practices of:

• Florida Pediatric Associates, LLC (FPA).
• Any health care professional authorized to enter information into your medical record maintained by FPA.
• Any persons or companies with whom FPA does business, e.g., “Business Associates.”
• All these persons, entities, sites, and locations follow the terms of this notice. In addition, these persons, entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes and other purposes described in this notice.

OUR PLEDGE REGARDING MEDICAL INFORMATION

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive from FPA. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the paper and/or electronic records of your care and billing for that care (collectively your Protected Health Information or PHI) generated or maintained by FPA, whether made by FPA personnel or other health care providers. Other health care providers may have different policies or notices about confidentiality and disclosure that apply to your PHI that is created in their offices or at locations other than FPA.

This notice will tell you about the ways in which we may use and disclose PHI about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your PHI. We are required by law to:

• Make sure that PHI that identifies you is kept private
• Give you this notice of our legal duties and privacy practices of FPA, and your legal rights, with respect to PHI about you
• Follow the terms of the notice that is currently in effect

HOW WE MAY USE AND DISCLOSE PHI ABOUT YOU

The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of these categories.

• For Treatment. We may use PHI about you to provide you with medical treatment or services. We may disclose PHI about you to doctors, nurses, technicians, medical students, volunteers, or other personnel who are involved in taking care of you at FPA. For example, a doctor treating you for a broken hip may need to know if you have diabetes because diabetes may slow the healing process. We also may disclose PHI about you to people outside FPA who may be involved in your medical care after you have been treated by FPA, such as friends, family members, or employees or medical staff members of any hospital or skilled nursing facility to which you are transferred or subsequently admitted.
• For Payment. We may use and disclose PHI about you so that the treatment and services you receive from FPA may be billed by FPA and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about treatment you received from FPA so your health plan will pay us or reimburse you for the treatment. We also may disclose information about you to another health care provider, such as a hospital or skilled nursing facility to which you are admitted, for their billing activities concerning you.
• For Health Care Operations. We and our business associates may use and disclose PHI about you for health care operations. These uses and disclosure are necessary to operate FPA and make sure that all of our patients receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine PHI about many patients to decide what additional services FPA should offer, and what services are not needed. We may also disclose information to doctors, nurses, technicians, and other personnel affiliated with FPA for review and learning purposes. We may also combine the PHI we have with PHI from other health care providers to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of PHI so others may use it to study health care and health care delivery without learning the identities of specific patients. We also may disclose information about you to another health care provider for its health care operations purposes if you also have received care from that provider.
• Treatment Alternatives. We may use and disclose PHI to inform you of potential treatment options or alternatives; or communicate with you regarding the scheduling, ordering or results of tests.
• Appointment Reminders. We may use and disclose your PHI to contact you and remind you of an appointment.
• Health Related Benefits and Services. Most uses and disclosures of for marketing purposes, and disclosures that constitute sale of protected health information require authorization.
• Individuals Involved in Your Care or Payment for Your Care. We may release PHI about you to a friend or family member who is involved in your medical care. This would include persons named in any durable health care power of attorney or similar document provided to us. We may also give information to someone who helps pay for some or all of your care. In addition, we may disclose PHI about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. You can object to these releases by telling us that you do not wish any or all individuals involved in your care to receive this information. If you are not present or cannot agree or object, we will use our professional judgment to decide whether it is in your best interest to release relevant information to someone who is involved in your care or to an entity assisting in a disaster relief effort.
• Individuals that Assist with Your Child’s Care. We may disclose PHI to individuals that assist with your child’s care (e.g. a babysitter, family friend, or relative) provided that the parent has provided us the names of those individuals that we are permitted to disclose PHI and provided that the individual accompanying your child presents a valid picture identification upon arrival to our office.
• As Required or Permitted by Law. We may disclose PHI about you when required or permitted to do so by federal, state, or local law such as for law enforcement purposes, suspected abuse or neglect reporting, health oversights or audits, funeral arrangements, organ donation, public health purposes or in the case of a medical emergency.
• To Avert a Serious Threat to Health or Safety. We may use and disclose PHI about you when it appears necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone who appears able to help prevent the threat and will be limited to the information needed.

SPECIAL SITUATIONS

• Organ and Tissue Donation. If you are an organ donor, we may release PHI to organizations that handle organ procurement or organ, eye, or tissue transplantation, or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.
• Active Duty Military Personnel and Veterans. If you are an active duty member of the armed forces or Coast Guard, we must give certain information about you to your commanding officer or other command authority so that your fitness for duty or for a particular mission may be determined. We may also release PHI about foreign military personnel to the appropriate foreign military authority. We may use and disclose to components of the Department of Veterans Affairs PHI about you to determine whether you are eligible for certain benefits.
• Workers’ Compensation. In accordance with state law, we may release without your consent PHI about your treatment for a work-related injury or illness or for which you claim workers’ compensation through your employer, insurer, or care manager paying for that treatment under a workers’ compensation program that provides benefits for work-related injuries or illness.
• Public Health Risks. We may disclose, without your consent, PHI to public health authorities that are authorized by law to collect information for the purpose of activities that generally include but are not limited to the following:To report, prevent, or control disease, injury, or disability
  • To report births and deaths
  • To report reactions to medications or problems with products
  • To notify people of recalls of products they may be using
  • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition
  • To report suspected abuse or neglect as required by law
  • To report child abuse or neglect
  • To prevent or control disease, injury or disability
  • To notify a person regarding potential exposure to a communicable disease
  • To notify a person regarding a potential risk for spreading or contracting a disease or condition
  • To report reactions to drugs or problems with products or devices
  • To notify individuals if a product or device they may be using has been recalled
• Health Oversight Activities. We may disclose, without your consent, PHI to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. The government uses these activities to monitor the health care system, government programs, and compliance with civil rights laws.
• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we must disclose PHI about you in response to a court or administrative order. We also may disclose PHI about you in response to a subpoena or other lawful process from someone involved in a civil dispute.
• Law Enforcement. We may release, without your consent, PHI to a law enforcement official:
  • In response to a court order, warrant, summons, grand jury demand, or similar process
  • To comply with mandatory reporting requirements for violent injuries, such as gunshot wounds, stab wounds, and poisonings
  • In response to a request from law enforcement for certain information to help locate a fugitive, material witness, suspect, or missing person
  • To report a death or injury we believe may be the result of criminal conduct
  • To report suspected criminal conduct committed at FPA facilities
• Coroners and Medical Examiners. We may release, without your consent, PHI to a coroner or medical examiner. This may be done, for example, to identify a deceased person or determine the cause of death. We may also release PHI about deceased patients of FPA to funeral directors to carry out their duties.
• National Security and Intelligence Activities. We may release, without your consent, PHI about you as required by applicable law to authorized federal or state officials for intelligence, counterintelligence, or other governmental activities prescribed by law to protect our national security.
• Protective Services for the President and Others. We may disclose PHI about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.
• Psychotherapy Notes. Regardless of the other parts of this Notice, psychotherapy notes will not be disclosed outside FPA except as authorized by you in writing or pursuant to a court order, or as required by law. Psychotherapy notes about you will not be disclosed to personnel working within FPA, except for training purposes or to defend a legal action brought against FPA, unless you have properly authorized such disclosure in writing.
• Inmates. If you are an inmate of a correctional institution or in the custody of law enforcement, we may release PHI about you to the correctional institution or law enforcement official who has custody of you, if the correctional institution or law enforcement official represents to FPA that such PHI is necessary: (1) to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) to protect the safety and security of officers, employees, or others at the correctional institution or involved in transporting you; (4) for law enforcement to maintain safety and good order at the correctional institution; or (5) to obtain payment for services provided to you. If you are in the custody of the [Name of State] Department of Corrections (DOC) and the DOC requests your medical records, we are required to provide the DOC with access to your records.

 

YOUR RIGHTS REGARDING PHI ABOUT YOU

You have the following rights regarding PHI we maintain about you:

· Right to Inspect and Copy. You have the right to inspect and receive a copy of your medical records, unless your attending physician determines that information in those records, if disclosed to you, would be harmful to your mental or physical health. If we deny your request to inspect and receive a copy of your PHI on this basis, you may request that the denial be reviewed. Another licensed health care professional chosen by FPA will review your request and the denial. The person conducting the review will not be the person who denied your request. We will do what this reviewer decides. 

If we have all or any portion of your PHI in an electronic format, you may request an electronic copy of those records or request that we send an electronic copy to any person or entity you designate in writing.

Your PHI is contained in records that are the property of FPA. To inspect or receive a copy of PHI that may be used to make decisions about you, you must submit your request in writing to the manager or administrator of the applicable FPA office. If you request the copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request, and we may collect the fee before providing the copy to you. If you agree, we may provide you with a summary of the information instead of providing you with access to it, or with an explanation of the information instead of a copy. Before providing you with such a summary or explanation, we first will obtain your agreement to pay and will collect the fees, if any, for preparing the summary or explanation.

· Right to Amend. If you feel that PHI we have about you in your record is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for FPA.

To request an amendment, you must submit your request in writing to the manager or administrator of the applicable FPA office. Your written request must include a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request to amend information that:

• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment
• Is not part of the PHI created or maintained by FPA
• Is not part of the information that you would be permitted to inspect and copy
• Has been determined to be accurate and complete

If we deny your request for an amendment, you may submit a written statement of disagreement and ask that it be included in your medical record.

· Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we have made of PHI about you during the past six years. To request this list or accounting of disclosures, you must submit your request in writing to the manager or administrator of the applicable FPA office and state whether you want the list delivered on paper or electronically. Your requested time period may not be longer than six years. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. We may collect the fee before providing the list to you.

· Right to Request Restrictions. Except where we are required to disclose the information by law, you have the right to request a restriction or limitation on the PHI we use or disclose about you. For example, you could revoke any and all authorizations you previously gave us relating to disclosure of your PHI. We are not required to agree to your request, with the exception of restrictions on disclosures to your health plan, as described below. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

To request restrictions, you must submit your request in writing to the manager or administrator of the applicable FPA office. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

You may request that we do not disclose your PHI to your health insurance plan for some or all of the services you receive during a visit to any FPA location. If you pay the charges for those services you do not want disclosed in full at the time of such service, we are required to agree to your request. “In full” means the amount we charge for the service, not your copay, coinsurance, or deductible responsibility when your insurer pays for your care. Please note that once information about a service has been submitted to your health plan, we cannot agree to your request. If you think you may wish to restrict the disclosure of your PHI for a certain service, please let us know as early in your visit as possible.  This requirement does not apply to disclosures for treatment, such as disclosures to a referring physician for continuation of care. This office is required to comply with any requests that limit disclosures to a health plan when the service has been paid out-of-pocket and in full by the patient. Such restrictions do not override disclosures that are otherwise required by law. Additionally, if initial payment for services, that have a request for restriction applied to them, is returned or invalid; our office will make a good faith attempt to collect payment – if this is unsuccessful we have the right to then submit a claim for these services to the health plan.

· Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail, or at another mailing address other than your home address. We will accommodate all reasonable requests. We will not ask you the reason for your request. To request confidential communications, make your request in writing to the Privacy Officer and specify how or where you wish to be contacted.

· Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice or any revised notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may request a copy of our Privacy Notice at any time by contacting the manager of this office or by contacting our Compliance Office.

MINORS AND PERSONS WITH LEGAL GUARDIANS:

Minors and certain disabled adults are entitled to the privacy protection of their health information. Because, by law, they cannot make health decisions for themselves, a parent or guardian can make medical decisions on their behalf. Therefore, parents and guardians can authorize the use and release of PHI and also hold all rights listed in this notice or the behalf of the minor child or disabled adult.

Under certain situations defined by law, minors can make independent healthcare decisions without parent or guardian knowledge or consent. In those situations, the minor may hold all rights listed in this notice. If the minor chooses to inform the parent or guardian, then all privacy rights regarding PHI may transfer to the parent or guardian. There are also certain situations where access, use or release of a minor’s PHI may occur without the consent of the parent or guardian, i.e. when the health or safety of the minor is in danger and PHI is necessary to protect the minor.

OTHER USES OF PHI

Other uses and disclosures of PHI not covered by this notice may be made only with your written authorization or as required by law. If you authorize us to use or disclose PHI about you, you may revoke that authorization, in writing, at any time. Your revocation will be effective as of the end of the day on which you provide it in writing to the administrator or manager of this office. If you revoke your permission, we will no longer use or disclose PHI about you for the purposes that you previously had authorized in writing. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each FPA office. The notice will contain the effective date on the first page, in the top right-hand corner. If the notice changes, a copy will be available to you upon request.

INVESTIGATIONS OF BREACH OF PRIVACY

We will investigate any discovered unauthorized use or disclosure of your PHI to determine if it constitutes a breach of the federal privacy or security regulations addressing such information. If we determine that such a breach has occurred, we will provide you with notice of the breach and advise you what we intend to do to mitigate the damage (if any) caused by the breach, and about the steps you should take to protect yourself from potential harm resulting from the breach.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with FPA or with the Secretary of the United Stated Department of Health and Human Services.  All complaints must be submitted in writing. You will not be penalized for filing a complaint.

To file a complaint with FPA, contact the Florida Pediatric Associates Compliance Office at:

1800 Dr. Martin Luther King Jr. Street North

St. Petersburg, FL 33704

Phone:   (866) 635-8765

E-mail: icomply@floridapediatrics.com

TERMS OF USE

TERMS OF USE ("TERMS")
These Terms of Use ("Terms") tell you terms on which you are permitted to use the FloridaPediatrics.com website ("Site"). Please read these Terms carefully before using the Site. You should read these Terms carefully. Your access to and use of the Site is conditioned on your acceptance of and compliance with these Terms. These Terms apply to all visitors, users and others who access or use the Site. By accessing or using the Site you agree to be bound by these Terms. If you disagree with any part of the Terms, then you may not access the Site.

INFORMATION ABOUT THE SITE
The Site is solely owned by Florida Pediatric Associates, LLC (“FPA”). FPA reserves the right to update or change the Terms and the Site at any time without notice to you. The most current version of the Terms is indicated by the Date of Revision and can be reviewed by revisiting this page.

USE OF THE SITE AND CONTENT
The purpose of the Site is to provide general information about FPA including the services we provide and the health plans that we serve. We provide a list of FPA Divisions that represent various medical, surgical and facility-based pediatric (and sometimes adult) clinical services at practice locations in Jacksonville, Orlando, St. Petersburg and Tampa. We provide links to certain FPA Division websites that further describe the services that a Division provides. This Site and the Services, including any updates, enhancements, and new features are subject to these Terms.

This site DOES NOT:

1. Provide medical advice.
2. Provide access to patient health information.
3. Make services or products available to the public.
4. Allow nor permit visitors, users and others who access or use the Site to post, link, store, share and otherwise make available certain information, text, graphics, videos, or other material ("Content").
5. Allow payments for clinical services you might obtain at any one of our practice locations.

NO ENDORSEMENTS
Links to other web sites or references to third parties are not intended to be endorsements of a third parties' products or services. You should read the privacy policy and terms of use of any third party websites before using those websites.

PRIVACY AND PROTECTION OF PERSONAL INFORMATION
The Site is not intended to collect any user or visitor information. Please do not try to post protected health information on the Site. This Site, like many other websites, uses cookies. Cookies are small pieces of information that are stored on your computer or mobile device when you visit a website. The Site uses a cookie that is native to Personal Home Page applications to create the website and is used to store and identify a user’s unique session identification for the purpose of managing user session on the website. The cookie is a session cookie that is deleted when all of the user browser windows are closed. By using the Site, you agree to the processing of your information and the use of the necessary cookies. In addition, Google Analytics sets cookies to help us accurately estimate the number of visitors to the website and what content is most popular. This helps to ensure that my website is responding to your needs in the best way possible. You can view Google's Privacy Policy at https://policies.google.com/privacy.

By using and browsing this Site, you consent to cookies being used in accordance with this Policy. If you do not consent, you must turn off cookies or refrain from using the site.

Most browsers allow you to turn off cookies. To do this, look at the HELP menu on your browser. Switching off cookies should not noticeably restrict your use of this website.

Finally, when linking out to other sites, please take a moment to review the privacy statement of the site you are linking to as well.

PERSONAL AND NON-COMMERCIAL USE LIMITATION
You may view and download material from the Site solely for your own personal and non-commercial use. You must keep all copyright and other proprietary notices on any copies of the material you use from this Site. You may not modify, copy, distribute, transmit, display, perform, reproduce, publish, license, create derivative works from, transfer, or sell any information or services obtained from the Site.

PERMITTED USE OF THE SITE

The Site may be used only for lawful purposes. The Site may not be used:

• To violate the law
• To harm or defraud anyone
• To send or transmit materials that could not be uploaded as content
• To transmit unsolicited promotional or advertising materials or spam
• To transmit any computer code, including (without limitation) any virus, worm, Trojan, time-bomb, logger, spyware, ransomware, or other harmful program or code that is intended, designed, or anticipated to cause harm or disruption to computers or networks
• To participate in a denial of service or other activity that is intended or likely to disrupt the efficient operation of the Site or any other website or computer network.

LIABILITY
All information contained on, or accessible through, the Site is provided on an "AS IS" basis. FPA does not warrant that it is accurate, complete, current or reliable. You use the Site at your own risk.

TRADEMARKS
The trademarks, logos, and service marks (collectively, "Trademarks") displayed on this site are registered and unregistered Trademarks of FPA and other Third Party content providers in the U.S. and/or other countries. No Trademark displayed on this site may be used without written permission of the owner of such Trademarks. Misuse of these Trademarks, or any other content on this site, is strictly prohibited. You are also advised that FPA will enforce their intellectual property rights. Any rights not expressly granted herein are reserved.

COPYRIGHT NOTICE
You may not copy, reproduce, republish, post, retransmit, or distribute in any way any of the information contained in this site without prior written consent of FPA. Unless otherwise noted, everything that you see or read on this site is copyrighted.

LINKING AND FRAMING
You may place a link to the Site on another website, in a fair and legal manner, so long as the link does not adversely affect the reputation of any health care professional or the Site. The link may not suggest any endorsement or approval of the other website by a health care professional. You may not frame the Site on any other website.

ENFORCEMENT OF TERMS
We have the right to determine whether there has been a violation of these Terms. If we determine the Terms have been violated, we have the right to determine the action that will be taken. The action to be taken may include (but not be limited to):

• Immediate termination of your right to use the Site. The termination may be temporary or permanent.
• Immediate removal of any content posted by you to the Site.
• Issuance of a warning or other communication to you.
• Legal proceedings against you, including seeking of damages (including indemnity) recovering all costs and losses suffered as a result of your violation of the Terms.
• Other forms of legal proceedings against you.
• Referral to law enforcement agencies for further action.

We will not be liable for any damages which you may suffer as a result of the foregoing actions.

TERMINATION
We may terminate or suspend access to our Site immediately, without prior notice or liability, for any reason whatsoever, including without limitation if you breach the Terms.

All provisions of the Terms which by their nature should survive termination shall survive termination, including, without limitation, ownership provisions, warranty disclaimers, indemnity and limitations of liability.

CHANGES
We reserve the right, at our sole discretion, to modify or replace these Terms at any time. If a revision is material, we will try to provide at least 30 days' notice prior to any new terms taking effect. What constitutes a material change will be determined at our sole discretion.

CONTACT US
If you have any questions about these Terms, please contact:

Compliance Officer
Florida Pediatric Associates, LLC
1800Dr. Martin Luther King Jr. Street North
St. Petersburg, FL 33704
icomply@floridapediatrics.com
(866)-635-8765

Effective Date: January 1, 2024

WEB SITE PRIVACY POLICY

INTRODUCTION
By using the Floridapediatrics.com website (www.smappsfl.com), you are accepting the practices described in this privacy policy. You are encouraged to review the privacy policy whenever you visit our site to make sure that you understand how any personal information you provide will be used.

WHAT INFORMATION WE COLLECT
The sole purpose of our Site is to provide general information to the public about our medical practice including the medical services we provide at various locations and the health plans that we participate with. We have NO need for visitor or user information. Simply put, we do not knowingly collect personally identifiable information UNLESS a visitor chooses to contact us through our E-mail link. Then, of course, we would have the sender’s E-mail address and any other personal information (e.g. mailing address or telephone number) that the sender voluntarily includes in the E-mail. We prefer that when a visitor chooses to contact us for further information that he or she simply sends an E-mail with no additional information. The information the sender provides is used to fulfill a request for additional information.

COOKIES
This Site, like many other websites, uses cookies. Cookies are small pieces of information that are stored on your computer or mobile device when you visit a website.

The Site uses a cookie that is native to Personal Home Page applications to create the website and is used to store and identify a user’s unique session identification for the purpose of managing user session on the website. The cookie is a session cookie that is deleted when all of the user browser windows are closed. By using the Site, you agree to the processing of your information and the use of the necessary cookies. In addition, Google Analytics sets cookies to help us accurately estimate the number of visitors to the website and what content is most popular. This helps to ensure that my website is responding to your needs in the best way possible. You can view Google's Privacy Policy at https://policies.google.com/privacy.

By using and browsing this Site, you consent to cookies being used in accordance with this Policy.

If you do not consent, you must turn off cookies or refrain from using the site. Most browsers allow you to turn off cookies. To do this, look at the HELP menu on your browser. Switching off cookies should not noticeably restrict your use of this website.

Finally, when linking out to other sites, please take a moment to review the privacy statement of the site you are linking to as well.

DISTRIBUTION OF INFORMATION
We may share information with governmental agencies or other companies assisting us in fraud prevention or investigation. We may do so when: (1) permitted or required by law, (2) trying to protect against or prevent actual or potential fraud or unauthorized transactions, or (3) investigating fraud which has already taken place. Otherwise, no information is ever provided to any third parties for marketing or any other purpose.

COMMITMENT TO DATA SECURITY
Any personally identifiable information that you provide is kept secure. Only authorized employees and agents who have agreed to keep information secure and confidential, have access to this information.

CONCERNS & COMPLAINTS
If you are concerned that we may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your protected health information, please contact us at the address listed below. It is our intent to protect and keep your protected health information confidential. Your alerting us of any concerns you may have is a necessary part of a continuous quality process we employ. You will, in no way, be retaliated against for filing a complaint. You may also send a written complaint to the US Department of Health and Human Services. For questions, concerns or complaints, please contact us at:

Compliance Officer
Florida Pediatric Associates, LLC
1800 Dr. Martin Luther King Jr. Street North
St. Petersburg, FL 33704
icomply@floridapediatrics.com
(866)-635-8765

Effective Date: January 1, 2024